Wednesday, June 1, 2016

Intradialytic hypotension(IDH)
during hemodialysis(HD) is a challenging clinical concern and often hard to
treat. After one has ruled out cardiac
disorder ( especially diastolic dysfunction), common medications and ideas
attempted are: midodrine pre dialysis, low temperature during dialysis, daily
short dialysis sessions, florinef use, steroids in the right clinical setting,
and sodium and or calcium profiling. Switching to peritoneal dialysis can be an
option as well. The
KDOQI guidelines recommends most of these above mentioned changes.

2.Sertraline:This anti- depressant has shown improvement in orthostatic hypotension. Both
retrospective and prospective studies in small number of patients demonstrated
that treatment with sertraline hydrochloride was associated with an improvement
in the hemodynamic parameters in patients with IDH. A recent randomized control
trial from Iran also showed good benefit with this agent in IDH. The dose one
can usually start is 50mg once a day and then max at 100mg daily per most
trials when used for IDH.

Rho
et al nicely demonstrated in a CJASN paper in 2008 that IDH patients experienced greater decreases in
both systolic and diastolic blood pressure during thedialysis session despite equivalent ultrafiltration in
both groups. AVP concentration did not increase in the IDH patients compared
with controls despite hypotensive episodes. As a result, many have tried to use
DDAVP as a treatment option for IDH.

As
early as 1990s, vasopressin was tried in 6 patients to help IDH in
one single center study with success. The largest study(17 patients) using this was from Iran. In that study, the treatment arm
received intranasal DDAVP (two puffs) 30 minutes before all HD. Hypotensive episode occurred 18 times (8.82%)
in vasopressin group compared with 125 times (61.27%) in placebo group and
there was a significant association between them (p=0.0001). In addition mean
arterial blood pressure in vasopressin group was 80.77 and in placebo group was
73.92 and also there was a significant association (p=0.0001). The mean Kt/v in
group 1 and 2 were 1.29 and 1.28 without any differences between them (p=0.896).
This might be another interesting option to consider in IDH. Risk of thrombotic events might be something to think
about.

4.Droxidopa

This agent has been approved by FDA
for autonomic neuropathy.. The trade name is Northera. Droxidopa is a
synthetic amino acid precursor which acts as a prodrug to the neurotransmitter
norepinephrine. Unlike norepinephrine, droxidopa is capable of crossing the
protective blood–brain barrier. Why in IDH? Well recently published
trial that was a placebo controlled, phase 2 study looked at efficacy and
safety of this agent in IDH. The
investigators looked at placebo vs 400mg vs 600mg dose. Increase indroxidopa intra-HD MAP were not significantly different
from placebo, althoughdroxidopa groups showed significant improvements in mean
SBP after HD of +4.8 ± 11.6 mm Hg (600-mg) and +3.4 ± 13.1 (400-mg) compared
with -4.4 ± 17.9 mm Hg in placebo, and the drop seen in mean nadir SBP pre- to
intra-HD was also reduced. HD terminations decreased 5-fold in the 600-mg group
and 2-fold in the 400-mg group, whereas the number of discontinuations stayed
unchanged in the placebo group. Treatment of both dosages were well tolerated. This
might be an interesting option as well. The most common side effects noted were
GI related.